Preoperative comprehensive warming care on hypothermia prevention and recovery quality in laparoscopic colon cancer surgery

Abstract

BACKGROUND

Although laparoscopic radical resection for colorectal cancer offers advantages such as minimal invasiveness and rapid recovery, the incidence of intraoperative hypothermia remains high, significantly affecting patient prognosis. Traditional intraoperative thermoprotection measures have limitations in addressing heat redistribution following anaesthetic induction and the sustained loss of body heat during prolonged surgery. This study hypothesises that a comprehensive preoperative warming strategy, which shifts the timing of thermal intervention to the preoperative period, can more effectively maintain stable core body temperature in patients, thereby reducing the incidence of hypothermia, preserving coagulation function and promoting postoperative recovery.

AIM

To investigate effects of preoperative warming on hypothermia and recovery in laparoscopic colon cancer surgery.

METHODS

From August 2021 to August 2025, 118 colon cancer patients undergoing laparoscopic radical resection were randomized into observation and control groups (n = 59 each). The control group received routine intraoperative warming, while the observation group received additional preoperative comprehensive warming. Comparisons included core temperature, hypothermia incidence, perioperative indicators, bleeding-related outcomes, coagulation function, and adverse reactions.

RESULTS

No significant differences were found in baseline data or preoperative temperature (P > 0.05). Compared with controls, the observation group had higher core temperature at 30 minutes, 1 hour, and end of surgery, and a lower hypothermia rate (11.86% vs 33.90%, P < 0.05). The observation group also showed shorter operative time, anesthesia recovery time, first flatus time, hospital stay, lower Visual Analog Scale score on day 1, less blood loss and drainage, and better mobility on day 1 (P < 0.05). Fewer patients required intraoperative transfusion (5.08% vs 15.25%, P < 0.05). Coagulation parameters remained stable postoperatively in the observation group and were significantly better than controls (P < 0.05). The total incidence of postoperative adverse events was lower in the observation group (3.39% vs 16.95%, P < 0.05).

CONCLUSION

Preoperative comprehensive warming effectively maintains core temperature, reduces hypothermia, protects coagulation, minimizes adverse reactions, and promotes recovery in laparoscopic colon cancer surgery.

Key Words: Preoperative comprehensive warming care; Laparoscopic radical resection of colon cancer; Hypothermia; Coagulation function; Postoperative recovery

Core Tip: This randomized controlled trial demonstrates that initiating comprehensive warming interventions before anesthesia induction effectively prevents intraoperative hypothermia in laparoscopic colon cancer surgery. The preoperative warming strategy not only maintains core temperature but also preserves coagulation function and significantly reduces postoperative shivering and recovery time, offering a practical and enhanced protocol for perioperative care to improve patient outcomes.

INTRODUCTION

Laparoscopic radical resection of colon cancer has become a routine procedure for treating colon cancer due to its advantages such as minimal trauma and rapid recovery[1]. However, intraoperative hypothermia is one of the common perioperative complications, and its incidence in this type of surgery remains high[2]. Intraoperative hypothermia usually refers to a core body temperature below 36.0 °C, which is mainly caused by factors such as inhibition of the thermoregulatory center caused by anesthetic drugs, prolonged exposure of body cavity to a cold environment, large amount of unwarmed irrigation fluid or carbon dioxide perfusion, and redistribution of body heat[3,4]. Hypothermia may not only cause chills and discomfort in patients, but is also closely related to a series of serious postoperative complications, including coagulation dysfunction, cardiovascular events, delayed drug metabolism and prolonged anesthesia recovery time, which directly affect the short-term recovery and prognosis of patients[5,6]. Traditional intraoperative warming measures are mostly concentrated in the intraoperative stage, such as the use of warming blankets and warming infusions, which have certain effects, but their preventive effect on the continuous heat loss during laparoscopic surgery is often insufficient[7]. In recent years, the concept of perioperative body temperature management has been shifting from passive warming to active pre-warming. The comprehensive preoperative warming nursing strategy emphasizes the initiation of systematic and multimodal warming interventions before the start of anesthesia, aiming to improve the patient’s basal body temperature and heat reserve, reduce the temperature redistribution drop after anesthesia induction, and thus lay the foundation for maintaining core body temperature stability throughout the surgical period[8,9]. This study aims to explore the specific impact of a systematic comprehensive preoperative warming nursing strategy on patients undergoing laparoscopic radical resection of colon cancer, in order to provide empirical evidence for the clinical construction of a more scientific and effective perioperative body temperature management program.

MATERIALS AND METHODS

General information

The study included 118 patients with colon cancer who underwent laparoscopic radical resection at our hospital between August 2021 and August 2025. Patients were randomly assigned to an observation group and a control group, with 59 patients in each group, using a random number table. The randomization process was conducted by researchers not involved in clinical care or data collection, using sealed, opaque envelopes to ensure confidentiality. Preoperative warming made blinding of patients and healthcare personnel impossible, but outcome assessors were unaware of the group assignments; therefore, a single-blind method was used for assessment.

Inclusion criteria: (1) Pathologically confirmed colon cancer meeting the indications for laparoscopic radical resection; (2) American Society of Anesthesiologists classification I-II; (3) Age 18-88 years; (4) Patients undergoing laparoscopic colon cancer surgery meeting the surgical indications; and (5) Sign the informed consent form.

Exclusion criteria: (1) Abnormal body temperature due to various factors before surgery; (2) Comorbid severe cardiac, pulmonary, hepatic, renal dysfunction, or thyroid disease affecting body temperature regulation; (3) Recent use of medications affecting body temperature regulation; and (4) History of previous abdominal surgery.

Methods

All patients underwent surgery in the same laminar flow operating room (temperature constant at 21-25 °C, humidity 30%-60%), with standardized anesthesia and surgical procedures performed by the same surgical team.

Anesthesia induction protocol: (1) Intravenous injection of midazolam 0.03-0.05 mg/kg; (2) Propofol 1.5-2.0 mg/kg; (3) Sufentanil 0.3-0.5 μg/kg; and (4) Rocuronium bromide 0.6-0.9 mg/kg.

Anesthesia maintenance protocol: Continuous infusion of propofol 4-8 mg/kg/hour and remifentanil 0.1-0.3 μg/kg/minute, with intermittent supplemental administration of rocuronium bromide to maintain muscle relaxation. Anesthesia depth was adjusted based on bispectral index (BIS) monitoring, maintaining a BIS value of 40-60. Intraoperative anesthetic drug dosages were individually adjusted according to patient weight and BIS value; there were no differences in anesthesia protocols between the two groups.

Control group: Received routine intraoperative warming care. Upon entering the operating room, patients received warming measures only during the operation, including: (1) Body covering: Non-surgical areas were covered with ordinary cotton blankets; (2) Fluid warming: All intravenous fluids and peritoneal lavage fluids were continuously warmed to 37 °C using a blood transfusion and infusion warmer before use; and (3) Intraoperative warming: Immediately after anesthesia induction, a standard inflatable warming blanket was applied to the patient’s trunk and lower extremities, with the blanket temperature set to 38 °C, and maintained until the end of the operation.

Observation group: In addition to routine intraoperative warming, a comprehensive preoperative warming care strategy was implemented, specifically as follows: (1) Preoperative assessment and education: One day before surgery, the circulating nurse conducted a visit to assess the patient’s general condition and thermoregulation risk factors, and explained in detail to the patient and family the dangers of intraoperative hypothermia and the importance of preventive measures, gaining their understanding and cooperation; (2) Preoperative warming: Before picking up the patient, the blankets were preheated using an inflatable warmer on the transport vehicle , set at 38-40 °C. Active warming of the torso and limbs was performed preoperatively , ensuring continuous warming for at least 30 minutes to increase the patient’s core and surface temperature before entering the operating room, increasing their heat reserves; (3) Warming during transport: During transport to the operating room, the patient’s entire body was tightly covered with preheated blankets from the operating room to minimize exposure time in transitional areas such as the preoperative area and avoid heat loss during transport; (4) Pre-anesthesia preparation and warming: Continuous surface warming. After the patient enters the operating room, disposable inflatable warming blankets are placed on the operating table to maintain warmth before anesthesia induction and during all preparations; (5) Environmental and material preheating: The fabrics used on the operating table are preheated. Small cotton pads or homemade shoulder pads are used to cover and warm limbs that need to be exposed; (6) Continuous fluid warming: After establishing intravenous access, all infused fluids are kept at a constant temperature of 37 °C using warming equipment; and (7) Continuous comprehensive warming during surgery: After anesthesia induction, inflatable warming blankets are used to maintain warmth, and intraoperative fluid warming is maintained according to the same standards. Simultaneously, carbon dioxide pneumoperitoneum is used for warming during surgery. Before inflating the CO₂ gas used to establish the surgical space into the abdominal cavity, it is heated to near body temperature (usually 37 °C) and humidified. Meanwhile, the circulating nurse strictly limits the number of times and the duration of opening the operating room door to maintain a constant indoor temperature and humidity.

Observation indicators

General information: (1) Gender; (2) Age; (3) Body mass index; and (4) American Society of Anesthesiologists classification.

Body temperature monitoring: Core body temperature was measured before surgery, 30 minutes during surgery, 1 hour during surgery and at the end of surgery (using nasopharyngeal temperature monitoring or wireless body temperature sensor). Hypothermia was defined as core body temperature ≤ 36 °C.

Perioperative indicators: (1) Operation time; (2) Anesthesia recovery time; (3) First flatus time; (4) Length of hospital stay; (5) Postoperative day 1 pain Visual Analog Scale (VAS) score; and (6) Postoperative day 1 activity level.

Intraoperative and postoperative bleeding-related indicators: (1) Record intraoperative blood loss; (2) Number of intraoperative blood transfusions; and (3) Abdominal drainage volume 24 hours postoperatively.

Coagulation function: The 3 mL of fasting venous blood was collected before and after surgery. Thrombin time (TT), prothrombin time (PT) and activated partial thromboplastin time (APTT) were measured using an automated coagulation analyzer in strict accordance with the reagent kit and instrument instructions.

Postoperative adverse reactions: Adverse reactions such as chills, agitation and tachycardia that occurred from the time of surgery until the patient’s full recovery were recorded.

Statistical analysis

SPSS 21.0 was used for statistical analysis. Continuous data were expressed as mean ± SD following a normal distribution, and the t-test was used for comparisons between groups. Count data were expressed as n (%), and the χ² test was used for differences in distribution between groups. P < 0.05 was considered statistically significant.

RESULTS

Comparison of general information between the two groups of patients

This study included 118 patients with colon cancer who underwent laparoscopic radical resection. Patients were randomly divided into an observation group and a control group, with 59 patients in each group. General characteristics were compared between the two groups, and there were no statistically significant differences (P > 0.05), indicating comparability (Table 1).

Table 1 Comparison of general information between the two groups of patients, n (%)/mean ± SD.

Variable	Observation group (n = 59)	Control group (n = 59)	χ²/t	P value
Gender			0.306	0.580
Male	30 (50.85)	33 (55.00)
Female	29 (49.15)	27 (45.00)
Age (years)	70.26 ± 6.05	70.43 ± 6.10	0.136	0.892
Body mass index (kg/m2)	22.86 ± 1.38	23.01 ± 1.40	0.591	0.556
American Society of Anesthesiologists classification			0.136	0.712
Level I	30 (50.85)	32 (53.33)
Level II	29 (49.15)	28 (46.67)

Comparison of core body temperature and incidence of hypothermia between the two groups of patients

There was no statistically significant difference in preoperative core body temperature between the two groups (P > 0.05); compared with the control group, the core body temperature in the observation group was significantly higher at 30 minutes during surgery, 1 hour during surgery, and at the end of surgery (P < 0.05); the incidence of hypothermia in the observation group was 7 cases (11.86%), which was significantly lower than that in the control group [20 cases (33.90%)] (P < 0.05), as shown in Table 2.

Table 2 Comparison of core body temperature and incidence of hypothermia between the two groups of patients, n (%)/mean ± SD.

Group	Preoperative	30 minutes during the operation	1 hour during surgery	After the operation	Incidence of hypothermia
Observation group (n = 59)	36.58 ± 0.42	36.61 ± 0.38	36.38 ± 0.41	36.45 ± 0.41	7 (11.86)
Control group (n = 59)	36.54 ± 0.45	36.08 ± 0.41	35.82 ± 0.39	36.02 ± 0.43	20 (33.90)
χ²/t	0.546	7.305	7.637	5.528	8.116
P value	0.586	< 0.001	< 0.001	< 0.001	0.004

Comparison of perioperative indicators between the two groups of patients

Compared with the control group, the observation group had significantly lower operation time, anesthesia recovery time, first flatus time, hospital stay, and VAS score on postoperative day 1, and significantly higher activity level on postoperative day 1 (P < 0.05), as shown in Table 3.

Table 3 Comparison of perioperative indicators between the two groups of patients, mean ± SD.

Group	Operation duration (minutes)	Anesthesia recovery time (minutes)	First exhaust time (hour)	Length of hospital stay (days)	Visual Analog Scale score on postoperative day 1 (points)	Activity level on postoperative day 1 (hours)
Observation group (n = 59)	2 13.54 ± 31.05	32.18 ± 5.61	55.81 ± 6.07	11.24 ± 1.25	3.12 ± 0.85	2.35 ± 1.12
Control group (n = 59)	2 32.50 ± 34.50	35.44 ± 5.24	59.16 ± 6.71	12.49 ± 1.49	3.86 ± 0.92	1.68 ± 0.95
t value	3.132	3.261	2.837	4.858	4.859	3.468
P value	0.002	< 0.001	< 0.001	< 0.001	< 0.001	0.001

Comparison of intraoperative and postoperative bleeding-related indicators between the two groups

Compared with the control group, the intraoperative blood loss and postoperative abdominal drainage volume in the observation group were significantly lower (P < 0.05); 3 patients (5.08%) in the observation group received blood transfusions during the operation, which was significantly lower than the 9 patients (15.25%) in the control group (P < 0.05), as shown in Table 4.

Table 4 Comparison of intraoperative and postoperative bleeding-related indicators between the two groups, n (%)/mean ± SD.

Group	Intraoperative blood loss (mL)	Postoperative 24-hour abdominal drainage volume (mL)	Intraoperative transfusion rate
Observation group (n = 59)	152.36 ± 45.28	85.42 ± 28.36	3 (5.08)
Control group (n = 59)	189.54 ± 52.31	112.58 ± 35.47	10 (16.95)
t value	4.134	4.603	4.487
P value	< 0.001	< 0.001	0.034

Comparison of coagulation function between the two groups of patients before and after surgery

In the observation group, there were no statistically significant differences in TT, PT, and APTT after surgery compared with those before surgery (P > 0.05). In the control group, all coagulation parameters were significantly prolonged after surgery compared with those before surgery (P < 0.05). Before surgery, there were no statistically significant differences in coagulation parameters between the two groups (P > 0.05). After surgery, TT, PT, and APTT in the observation group were significantly shorter than those in the control group (P < 0.05), as shown in Table 5.

Table 5 Comparison of coagulation function before and after surgery in the two groups of patients, mean ± SD.

Group	Thrombin time		Prothrombin time		Activated partial thromboplastin time
	Before surgery	Post-surgery	Before surgery	Post-surgery	Before surgery	Post-surgery
Observation group (n = 59)	17.38 ± 1.22	17.55 ± 1.31	11.59 ± 1.37	11.78 ± 1.45	32.45 ± 2.38	32.58 ± 2.51
Control group (n = 59)	17.41 ± 1.19	18.46 ± 1.54a	11.63 ± 1.41	12.71 ± 1.68a	32.52 ± 2.41	34.25 ± 2.98a
t value	0.132	3.463	0.174	3.237	0.153	3.305
P value	0.895	0.001	0.862	0.002	0.879	0.001

^aP < 0.05 vs preoperative values in this group.

Comparison of adverse reaction rates between the two groups

The total incidence of postoperative adverse reactions in the observation group was 3.39%, which was significantly lower than that in the control group (16.95%) (P < 0.05), as shown in Table 6.

Table 6 Comparison of adverse reaction rates between the two groups, n (%).

Group	Cold war	Restlessness	Tachycardia	Overall incidence
Observation group (n = 59)	0 (0.00)	1 (1.69)	1 (1.69)	2 (3.39)
Control group (n = 59)	5 (8.47)	4 (6.78)	1 (1.69)	10 (16.95)
χ²				5.937
P value				0.015

DISCUSSION

As a common malignant tumor of the digestive system, colorectal cancer ranks third and fifth in incidence and mortality among malignant tumors in China, respectively, and has become a serious public health problem[10]. With the advancement of medical technology, laparoscopic radical surgery has significant advantages such as minimal trauma, clear vision, and rapid postoperative recovery, and has become the preferred surgical procedure for treating colorectal cancer[11]. Although laparoscopic surgery has lower trauma and fewer complications, it is still an invasive treatment, and the incidence of intraoperative hypothermia in patients remains high[12]. Intraoperative hypothermia refers to a core temperature below 36 °C during the perioperative period. Although it can temporarily reduce the body’s consumption, it will have adverse effects on the circulatory system, immune system, etc., thereby limiting the surgical effect, reducing safety, and even threatening the patient’s life[13,14]. The occurrence of intraoperative hypothermia is related to a variety of factors, such as the operating room environment. The operating room temperature is generally maintained at 22 °C, which can meet some surgical needs while maintaining a sterile environment. For patients undergoing surgical treatment, the body’s thermoregulatory center is suppressed under anesthesia, and the lower temperature at this time will cause the patient to lose heat through convection and develop hypothermia[15]. Comprehensive warming care measures in response to relevant factors can effectively reduce the patient’s body temperature drop and ensure that the patient completes treatment at a normal body temperature.

The results of this study found that, in terms of the effect of body temperature management, the core body temperature of the patients in the observation group was significantly higher than that of the control group at 30 minutes during the operation, 1 hour during the operation, and at the end of the operation, and the incidence of hypothermia (11.86%) was significantly lower than that of the control group (33.90%). The reasons for this are: (1) Pre-warming with an inflatable warming blanket 30 minutes before the operation directly increased the surface and core temperature of the patients, increased the body’s heat reserves, and effectively buffered the sudden drop in body temperature caused by the redistribution of body heat from the core to the periphery due to vasodilation after anesthesia induction[16]; (2) Continuous warming during the transportation process and the pre-anesthesia preparation period blocked the heat loss of the patients from entering the operating room to the start of anesthesia; and (3) Continuous comprehensive warming during the operation: Disposable inflatable warming blankets were used to maintain the warming, carbon dioxide pneumoperitoneum was used for warming during the operation, and liquid warming throughout the operation avoided the direct impact of cold liquid input on the core temperature. APTT and PT are important indicators reflecting intrinsic and extrinsic coagulation pathways, respectively, while TT helps to assess fibrinogen function and anticoagulant status[17,18]. Under normal circumstances, the body’s coagulation and fibrinolytic systems are in a state of balance, maintaining normal blood flow and hemostasis. However, intraoperative hypothermia can disrupt this balance. The mechanisms include inhibiting platelet function, reducing thrombin activity, and interfering with the coagulation cascade reaction, thereby leading to coagulation dysfunction and increasing the risk of intraoperative and postoperative bleeding[19,20]. Clinical studies have confirmed[21] that postoperative wound bleeding and increased abdominal drainage are often related to hypothermia-related coagulation disorders. The results of this study showed that the coagulation function indicators of the observation group did not change significantly after surgery compared with those before surgery, while those of the control group were prolonged compared with those before surgery. Although the magnitude was small, combined with the improvement in intraoperative blood loss, transfusion rate, and postoperative drainage in the observation group, it shows that even slight changes in coagulation function may be transformed into observable clinical bleeding risk under perioperative stress. In addition, no systemic anticoagulants were used by any patients during the procedure in this study, and the peritoneal infusion fluid was normal saline without heparin, thus eliminating the interference of the above factors on the coagulation results.

Regarding postoperative recovery, the observation group showed significantly lower operation time, anesthesia recovery time, first flatus time, hospital stay, and VAS score on postoperative day 1, and significantly higher activity level on postoperative day 1, demonstrating the positive impact of comprehensive warming strategies on promoting patient recovery. The reasons are as follows: (1) Maintaining normal body temperature avoids the interruption or delay of operation due to the treatment of severe hypothermia or intraoperative shivering, ensuring the smooth and efficient progress of the operation process and shortening the operation time; (2) Normal body temperature ensures that liver metabolic enzymes are in the best activity state, accelerates the biotransformation and clearance of anesthetic drugs, promotes the rapid recovery of patient consciousness, and shortens the anesthesia recovery time[22]; (3) Stable body temperature effectively reduces the stress response caused by the superposition of surgery and hypothermia, which is conducive to protecting gastrointestinal blood flow and nerve function and promoting early recovery of intestinal peristalsis[23]; and (4) By maintaining normal body temperature, improving the patient’s perioperative comfort, and reducing the risk of hypothermia-related complications, better recovery conditions are created for the patient, and the hospitalization time is shortened. Shivering is the most common adverse reaction caused by intraoperative hypothermia. It is essentially a compensatory muscle tremor caused by the body to generate heat to maintain core temperature[24]. Shivering can significantly increase the body’s metabolic rate, leading to increased oxygen consumption, carbon dioxide and lactic acid production, which may induce acidosis[25]. At the same time, shivering can trigger sympathetic nerve excitation, which increases heart rate and cardiac load, thereby significantly increasing the risk of cardiac adverse events such as myocardial ischemia and arrhythmia[26,27]. In addition, severe shivering interferes with the accuracy of monitoring vital signs such as electrocardiogram and blood pressure, affecting the timely and accurate judgment of the patient’s postoperative status by medical staff. Hypothermia is also an important cause of restlessness during the recovery period. The discomfort such as feeling cold and numb all over the body caused by the drop in body temperature during surgery can affect hemodynamic stability and become a cause of restlessness during the recovery period[28]. Agitation not only increases the risk of unplanned extubation, falls from bed, and catheter dislodgement, but the accompanying increase in blood pressure and heart rate is especially dangerous for patients with cardiovascular and cerebrovascular diseases[29]. Studies[30] have shown that for every 1.5 °C decrease in core body temperature, the incidence of tachycardia increases significantly, and the risk of related cardiac complications increases exponentially. Hypothermia itself can inhibit myocardial contractility, and in the context of reduced metabolism and relatively reduced oxygen demand, it may aggravate the imbalance of myocardial oxygen supply, inducing or aggravating myocardial ischemia. The results of this study showed that the total incidence of postoperative adverse reactions in the observation group was 3.39%, which was significantly lower than 16.95% in the control group. This indicates that comprehensive preoperative warming care can effectively prevent the occurrence of adverse reactions such as shivering and agitation, and ensure the safety of patients during the recovery period.

The comprehensive preoperative warming care strategy implemented in this study requires a certain investment in nursing staff and consumables, such as inflatable warming devices, disposable warming blankets and pre-warmed quilts; however, the clinical benefits it yields offset these costs. Firstly, the length of stay in the observation group was significantly shorter than that in the control group. Based on the hospital’s average daily cost of approximately 1500 yuan, this resulted in a saving of approximately 1875 yuan per patient. Secondly, the incidence of postoperative adverse reactions in the observation group was significantly lower than in the control group, reducing the additional nursing time and medication costs required to manage complications such as shivering and agitation. Furthermore, stable body temperature ensured the smooth progression of the surgical procedure, shortening both operating time and anaesthetic recovery time, and improving operating theatre turnover efficiency. In summary, the short-term investment in this protocol yields positive health economic benefits through reduced length of stay and lower costs associated with managing complications. For large hospitals facing nursing staff shortages, implementation costs can be reduced by optimising workflows – such as moving the pre-warming phase to the ward to be carried out by the ward nurse and using reusable warming devices – making it highly feasible for clinical implementation.

CONCLUSION

In conclusion, this study demonstrates that compared to routine intraoperative warming, implementing a comprehensive preoperative warming strategy can more effectively maintain stable core body temperature in patients undergoing laparoscopic radical resection of colon cancer during the perioperative period, significantly reduce the incidence of hypothermia and related complications, and promote postoperative recovery. Limitations and future prospects: This study was a single-center randomized controlled trial with a relatively limited sample size. Future multi-center, large-sample studies can be conducted to further validate the generalizability of the findings. Furthermore, this study primarily observed short-term indicators; future studies can further track long-term patient outcomes, such as surgical site infection rates and long-term quality of life, to more comprehensively evaluate the long-term benefits of the comprehensive warming strategy.